Provider First Line Business Practice Location Address: 
1100 N GARDNER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SCOTTSBURG
    Provider Business Practice Location Address State Name: 
IN
    Provider Business Practice Location Address Postal Code: 
47170-1418
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
812-752-5065
    Provider Business Practice Location Address Fax Number: 
812-752-1320
    Provider Enumeration Date: 
07/02/2006